- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,398.83
| Facility | | $1,202.26 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,621.81 / $2,754.23
| Professional | | $1,380.38 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,630.78 / $5,011.87
| Facility | | $3,090.30 | $3,630.78 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,698.24 / $2,137.96
| Professional | | $1,096.48 | $1,698.24 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,778.28 / $3,548.13
| Professional | | $1,148.15 | $1,778.28 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,265.80 / $6,309.57
| Facility | | $1,479.11 | $4,265.80 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,479.11 / $2,454.71
| Professional | | $1,148.15 | $1,479.11 | $2,454.71 |